The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-analysis.

Rollins KE, Javanmard-Emamghissi H, Acheson AG, Lobo DN. Ann Surg. 2019 Jul;270(1):43-58. doi: 10.1097/SLA.0000000000003145.

What is already known:
The use of mechanical bowel preparation (MBP) has always been an area of controversy, in fact was the subject of a fascinating pro-con debate at the ERAS Congress in Lyon. Current evidence would suggest that it does not impact on morbidity or mortality, so its routine use is not indicated. However the use of oral antibiotics (OAB) before surgery to reduce surgical site infections (SSI) has reignited that debate, or at least muddied the water.

What this paper adds:
This is a meta-analysis of a large number of patients undergoing elective bowel surgery. They received OAB with or without MBP. OAB + MBP showed a significant reduction in SSI, anastomotic leak, 30-day mortality, overall morbidity and development of ileus. OAB vs OAB + MBP showed no difference in SSI or anastomotic leak but did show a reduction in 30-day mortality and ileus with the combination. It would seem that OABs have a role in reducing a number of different postoperative complications, but we need more high quality evidence to say whether the OABs showed be combined with MBP or not.

Chris Jones, Guildford. @chrisnjones


Enhanced recovery care after colorectal surgery in elderly patients. Compliance and outcomes of a multicenter study from the Spanish working group on ERAS.

Gonzalez-Ayora S, Pastor C, Guadalajara H, Ramirez JM, Royo P, Redondo E, Arroyo A, Moya P, Garcia-Olmo D. Int J Colorectal Dis. 2016 Sep;31(9):1625-31. doi: 10.1007/s00384-016-2621-7. Epub 2016 Jul 4.

What is already known:
The benefits of ERAS for patients undergoing colorectal surgery is well known. However, the benefits to specific patient groups in particular the elderly, is less well known.

What this paper adds:
This is a multicentre non-randomised retrospective analysis of patients over 70 years old undergoing colon or rectal surgery in three Spanish tertiary hospitals. Their ERAS programme comprised ten main elements. 188 patients over 70 underwent surgery [median 79 (70-93)]. Global compliance of the elements was a less than impressive 56% overall. Only 44% of patients underwent laparoscopic surgery; 43% of patients did not have an abdominal drain; only 64% had their urinary catheter removed promptly and 67% had epidural analgesia. However, 90% of patients underwent early mobilisation and early intake of clear fluids. Overall length of stay was 6 days. The authors found that with increasing compliance length of stay decreased, and importantly only 6.4% of patients were readmitted to hospital after discharge. The study showed that ERAS after colorectal surgery is safe and feasible, and that age is no barrier to an effective programme.

Chris Jones, Guildford. @chrisnjones


Recovery of gastric ileus following laparoscopic ventral rectopexy within an enhance recovery protocol

Kiyasu Y, Tsunoda A, Ohta T, Kusanagi H. Recovery of gastric ileus following laparoscopic ventral rectopexy within an enhance recovery protocol. Surg today. 2016 Aug;46(8):895-900.

What is already known:

Early oral feeding after surgery has become one of the key elements of ERAS protocols facilitating earlier hospital discharge. Historically laparoscopic ventral rectopexy as a treatment for rectal prolapse has been associated with a median length of stay of 3-6 days. This single centre study aimed to look at the degree of gastric ileus recovery by the postoperative evening using an ERAS protocol.

What this paper adds:

This study looked at the use of gastric ultrasound to evaluate the pyloric area as a surrogate for identifying gastric ileus. Scans were performed both pre and post-surgery, before and after ingestion of a standardised carbohydrate solution. They report that gastric ileus had resolved in most patients within 5 hours postoperatively and 90% of patients were discharged on the day following surgery having met full discharge criteria. They acknowledge that this is a small study of 40 patients, and it is unclear whether the ERAS protocol is responsible for the reduced length of stay and resolution of gastric ileus.

This study provides further evidence to support early oral feeding as part of ERAS protocols. Their full ERAS protocol was published however the use of NG tubes and thoracic epidurals for laparoscopic cases appears at odds with current ERAS guidelines.

Katie Wimble, Guildford. @wimble_katie


Promoting a culture of prehabilitation for the surgical cancer patient

Carli F, Gillis C, Scheede-Bergdahl C. Promoting a culture of prehabilitation for the surgical cancer patient Acta Oncol. 2017 Feb;56(2):128-133.

What is already known:
Poor functional capacity is known to affect outcomes after surgery. Focus has now turned away from the postoperative to the preoperative phase and help prepare a patient for the insult that is surgery. But it is not just physical fitness; a cancer diagnosis can also have other affects on a patient, such as sarcopenia and malnutrition, as well as detrimental psychological effects. So the preoperative period is potentially an ideal time to make improvements in nutritional status and psychological health.

What this paper adds:
This interesting Canadian article reviews the literature on not only exercise programs, but also how to optimise nutritional status, and how psychological distress can influence functional capacity.

Chris Jones, Guildford. @chrisnjones


Effect of Diagnosis on Outcomes in the Setting of Enhanced Recovery Protocols

Ban KA, Berian JR, Liu JB, Ko CY, Feldman LS, Thacker JKM (2018) Effect of Diagnosis on Outcomes in the Setting of Enhanced Recovery Protocols. Dis Colon Rectum. 2018 Jul;61(7):847-853.

What is already known:

A patient’s underlying diagnosis necessitating surgery is one of a number of factors previously shown to affect outcomes for patients undergoing colorectal surgery outside of an ERAS programme. Inflammatory bowel disease and acute mesenteric ischaemia appear to confer the highest risk of adverse outcomes alongside non-elective surgery and pre-existing comorbidities.

What this paper adds:

This paper looks retrospectively at outcomes for patients enrolled in an ERAS programme to see whether the underlying diagnosis remains an important predictor of outcome. Patients with neoplastic disease were found to be significantly more likely to have an ASA grade of III to V and have a higher risk of undergoing open surgery. Although ERAS compliance did not significantly differ between the diagnosis groups, overall compliance was generally underwhelming with only around a third of patients complying with 10 or more elements. This was a database analysis covering multiple centres thus details of individual ERAS programmes are not given. Overall, patients with IBD still appear to be at highest risk of serious complications despite the use of ERAS elements. It was noted that the extent of surgery in IBD patients was higher than in cancer or diverticular disease patients. The authors do comment on possible selection bias resulting from IBD patients being less likely to be enrolled on ERAS programmes or that those who were had a lower disease burden. The authors conclude that tailoring the patient education element of ERAS programmes for IBD patients may help improve their outcomes.

Ben Morrison, Guildford. @blouism


The Use of the Enhanced Recovery After Surgery (ERAS) Protocol in PatientsUndergoing Laparoscopic Surgery for Colorectal Cancer–A Comparative Analysis of Patients Aged above 80 and below 55.

Pędziwiatr M, Pisarska M, Wierdak M, Major P, Rubinkiewicz M, Kisielewski M, Matyja M, Lasek A, Budzyński A (2015) The Use of the Enhanced Recovery After Surgery (ERAS) Protocol in Patients Undergoing Laparoscopic Surgery for Colorectal Cancer–A Comparative Analysis of  Patients Aged above 80 and below 55. Pol Przegl Chir. 2015 Nov;87(11):565-72.

What is already known:

With increasing frailty and co-morbidities, age is often thought of as a barrier to successful outcomes after surgery. In this single centre Polish study, they compare post-operative outcomes in patients over the age of 80 years with those under the age of 55.

What this paper adds:
This was a small retrospective review of prospectively recorded data. All patients underwent laparoscopic colorectal surgery and followed a comprehensive ERAS program. Mean length of hospital stay was not significantly different between groups [5.4 days (>80yrs) vs 7 days (<55yrs), p=0.44]; nor postoperative complications or readmissions. Overall compliance of ERAS elements was impressively high in both groups [85% vs 83%]. Early mobilisation (<2 hours post-op) was also not impaired in the over 80 group [94% compliance vs 83%]. The only difference found, was that only 26% of >80yrs required opioids postoperatively compared with 55% of the <55yrs group. This study adds to the evidence that age should not be a barrier to surgery and that patients over the age of 80 can have similar outcomes to much younger patients.

Chris Jones, Guildford.  @chrisnjones


Perioperative Standard Oral Nutrition Supplements Versus Immunonutrition in Patients Undergoing Colorectal Resection in an Enhanced Recovery (ERAS) Protocol: A Multicenter Randomized Clinical Trial (SONVI Study)

Moya P, Soriano-Irigaray L, Ramirez JM, Garcea A, Blasco O, Blanco FJ, Brugiotti C, Miranda E, Arroyo A. (2016) Perioperative Standard Oral Nutrition Supplements Versus Immunonutrition in Patients Undergoing Colorectal Resection in an Enhanced Recovery (ERAS) Protocol: A Multicenter Randomized Clinical Trial (SONVI Study). Medicine (Baltimore). 2016 May;95(21):e3704.

What is already known: The evidence base for recommending immunonutrition is low and current ESPEN guidelines only recommend it for malnourished patients undergoing major cancer surgery. However, the most recent ERAS society guidelines do recommend immunonutrition based more on lack of harm rather than the quality of evidence base. This study is a multicentre RCT comparing an immune enhancing feed with a hypercaloric high-protein supplement in all patients undergoing colorectal surgery; and the first in patients following an ERAS pathway.

What this paper adds: 244 patients were randomised to the two different supplements. Both groups followed a comprehensive ERAS programme and all other aspects of perioperative care were the same. Overall post-op complications were reduced in the immunonutrition group [23% vs 35%, p=0.035]; but in particular postoperative infectious complications [10.7% vs 23.8%, p=0.007]. This paper strengthens the evidence base for the use of immunonutrition as part of an ERAS pathway.

Chris Jones, Guildford.  @chrisnjones


Enhanced Recovery After Surgery: Can We Rely on the Key Factors or Do We Need the Bel Ensemble?

Jurt J, Slieker J, Frauche P, Addor V, Solà J, Demartines N, Hübner M (2017)Enhanced Recovery After Surgery: Can We Rely on the Key Factors or Do We Need the Bel Ensemble? World J Surg. 2017 Oct;41(10):2464-2470. 

 

What is already known:

Lots of studies have shown that the higher the compliance with the ERAS elements the better the outcomes (both long and short; however, a lot of institutions find it difficult to adhere to all elements. This paper aims to assess the impact of each element to outcomes.

What this paper adds:

Minimally invasive surgery in this study was associated with reduced complications. However, the use of NG tubes, prophylactic abdominal / pelvic drains, thoracic epidurals and a high ASA score were all independent risk factors for complications. Like other papers looking at adherence, they found that with increasing adherence the better the outcomes and lower the complications. The threshold for adherence with the elements was 70%, below which complications rose and length of hospital stay increased.

Chris Jones, Guildford. @chrisnjones


Patient-reported outcomes 6 months after enhanced recovery after colorectal surgery

Deiss T, Chen L, Sarin A, Naidu RK. Perioperative Medicine (2018) 7:19

What is already known:

Many post-operative outcomes have been investigated and have been shown to be improved following implementation of an ERAS programme. The vast majority of these relate to inpatient stay and short-term (most commonly 30-90day) outcomes. Some studies have looked at longer-term outcomes including mortality and chronic pain and there is a strong association between chronic pain and opioid dependence.

What this paper adds:

This observational study identified a significant proportion of patients reporting persistent post-surgical pain (19%), dissatisfaction with their stay (14%) and hospital readmission (20%) within six months of their operation. These findings may suggest that a significant proportion of patients are suffering in the long-term following surgery despite being enrolled in an ERAS programme. The study did not, however, compare to outcomes before rolling-out an ERAS programme, nor did it give details of the programme itself. This study has demonstrated the potential for utilising automated telephone services as a screening tool for patients who may have experienced significant adverse outcomes postoperatively although they only achieved a 48% response rate. In an era where there is increasing concern over long-term opioid dependence, any methods which may help identify patients who have become opioid dependent should be investigated further.

Ben Morrison, Guildford. @blouism


Incidence of venous thromboembolic events in enhanced recovery after surgery for colon cancer: a retrospective, population-based cohort study.

Colorectal Dis. 2017 Nov;19(11):O393-O401.

 

What is already known:

VTE prophylaxis is an important but an often overlooked element of ERAS programmes. In the past VTE has a high morbidity and mortality, and most National guidelines have used old pre-ERAS evidence to base their recommendations. But now with ERAS programmes improving early mobilisation how has this affected the rate of symptomatic VTE, and in particular with only short-term VTE prophylaxis?

What this paper adds:

This Danish group conducted the first population-based cohort study to investigate the effect of in hospital only thromboprophylaxis within a colorectal ERAS programme. The risk of symptomatic venous thromboembolic events was found to be very low – only 0.2%. Raising the question of how beneficial is prolonged VTE prophylaxis for patients undergoing colorectal surgery within an ERAS programme. Randomised trials are warranted and national guidelines recommending prolonged thromboprophylaxis should be reconsidered.

Chris Jones, Guildford. @chrisnjones


American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery

Anesth Analg. 2018 Jun;126(6):1896-1907.

What is already known:

A delayed return to normal GI function or the development of ileus will likely prolong hospital length of stay and several elements of ERAS are aimed towards the avoidance of GI complications. A number of definitions of ileus exist with considerable variation in their diagnostic criteria.

What this paper adds:

This paper is written by the Perioperative Quality Initiative (POQI) 2 workgroup, an international collaborative of experts in anaesthesia, surgery, nutrition and nursing. In order to better define ileus and aid in ascertaining its true incidence the group propose a rational definition of ileus or Post-Operative Gastrointestinal Dysfunction (POGD). The group propose a scoring system (I-FEED) comprising five elements helping to diagnose POGD. They go on to recommend a number of strategies aimed at reducing the incidence of POGD, several of which are found in ERAS protocols such as multimodal analgesia (with opioid avoidance) and avoidance of NG tubes. Other elements such as the use of chewing gum, coffee and alvimopan are reviewed and evidence-graded. The paper also includes evidence-based treatment strategies for patients developing POGD.

Dr Ben Morrison


Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals

Aarts MA, Rotstein OD, Pearsall EA, Victor JC, Okrainec A, McKenzie M, McCluskey SA, Conn LG, McLeod RS; iERAS group. Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals. Ann Surg. 2018 Jun;267(6):992-997.

[And accompanying editorial: Ann Surg. 2018 Jun;267(6):998-999. ERAS Implementation-Time To Move Forward. Kehlet H.]

What is already known:

A great deal of work has already been done demonstrating how improved compliance with ERAS elements can improve both short-term and long-term outcomes. This is often in a ‘dose-dependent’ fashion with increasing compliance of all elements [e.g. Gustafsson – Arch Surg 2011, Pecorelli – Surg Endos 2016, ERAS Compliance Group – Annals of Surg 2015].

What this paper adds:

This group was made up of clinicians from 15 academic hospitals in Ontario, and setup their own version of an ERAS pathway. The original project demonstrated a small 1 day improvement in length of stay with no change in readmissions. This paper aimed to determine which components of their ERAS programme had the greatest effect on recovery in colorectal surgery. This is a large study of almost 3000 patients conducted over a two-and-a-half-year period. Their self-designed programme only used 12 elements and were divided into pre, intra and post-operative pathways, with each having 4 elements. And therefore missed out on intra-operative elements such as temperature control, antibiotics etc, but also important pre-operative ones such as pre-optimisation inc prehabilitation. Patients were deemed compliant if they achieved at least 75% compliance (3 out of 4 of the elements in each pathway).
Only 20.1% of all patients were compliant with all 3 pathways. Whilst 74.7% were compliant with the pre-operative elements only 40.3% were compliant with the post-operative elements. There were some excellent gains from baseline for example rates of preoperative counselling doubled from 41.4% to 82.2% and use of CHO went from 0% to 82%, after introduction of the programme. However, some elements were still poorly adhered to, e.g. use of goal-directed fluid therapy at only 26.7%. The authors suggest this is purely down to the fact that there was no additional funding available to the sites. But other more simple interventions were also not well adhered to, e.g. use of chewing gum post-operatively was only at 52.5%.
Two potentially modifiable factors were found to significantly impact patient outcomes: laparoscopic surgery and preoperative haemoglobin levels. (A number of RCTs are in progress looking at how preoperative intravenous iron therapy can influence outcomes.) Overall higher compliance improved outcomes in both the laparoscopic and open group but the impact was significantly higher in the open group.
The authors should be congratulated on size of the study and the multi-centred nature and the fact that it was prospective. But there were a number of limitations including only recording data from patients who consented, which could be a biased towards those patients who were naturally more motivated to follow the programme. The other issue is that as an observational study causation cannot be proved but only inferred. What are the real reasons for failure in following the post-operative elements? Are there proper medical / surgical reasons or simply organisational or logistical reasons? This is where our focus needs to be in the future and how to improve the compliance of all elements.

Chris Jones, Guildford.


Pre- and postoperative stoma education and guidance within an enhanced recovery after surgery (ERAS) programme reduces length of hospital stay in colorectal surgery.

Forsmo HM, Pfeffer F, Rasdal A, Sintonen H, Körner H, Erichsen C. Pre- and postoperative stoma education and guidance within an enhanced recovery after surgery (ERAS) programme reduces length of hospital stay in colorectal
surgery. Int J Surg. 2016 Dec;36(Pt A):121-126. doi: 10.1016/j.ijsu.2016.10.031. Epub 2016 Oct 22.

What is already known:

In most colorectal ERAS RCTs, patients undergoing stoma formation are often excluded. This small single-centre study looked specifically at patients undergoing colorectal surgery with stoma formation.

What this paper adds:

Whilst the authors did not define the specifics of their ERAS programme they did detail how their stoma nurse specialists focused on preoperative counselling and stoma education. Their programme demonstrated a 3 day reduction in hospital length of stay; showing that with proper preparation, undergoing stoma formation does not necessarily need to be a barrier against following a successful ERAS programme.

Chris Jones, Guildford.


Impact of mechanical bowel preparation in elective colorectal surgery: a meta-analysis

Katie E Rollins, Hannah Javanmard-Emamghissi, Dileep N Lobo.Impact of mechanical bowel preparation in elective colorectal surgery: a meta-analysis. World J Gastroenterol 2018 January 28; 24(4): 519-536

What is already known:

Mechanical bowel preparation (MBP) has long been part of surgical dogma; the rationale behind its use is that it reduces faecal bulk and, therefore bacterial colonisation, thereby reducing the risk of postoperativecomplications such as anastomotic leakage and wound infection, but slowly its routine use has been questioned. It has numerous physiological adverse effects secondary to the dehydration caused, it is distressing for the patient and is associated with prolonging ileus after surgery. There is also concern that it liquefies faeces and so may increase risk of spillage and therefore infection postoperatively. It remains somewhat controversial with advocates on both sides. In fact, it was even the subject of a Pro / Con debate at last year’s ERAS congress in Lyon.

What this paper adds:

This is an excellent and comprehensive meta-analysis by Professor Lobo’s group in Nottingham [NB Prof Lobo is the ERAS Society Scientific Chair]. It follows nicely on from the Cochrane review [2011], but with a further 5 RCT’s and includes over 21,500 patients versus almost 6000 in the Cochrane review. It demonstrates that at present there is no evidence that bowel preparation makes a difference to clinical outcomes in either colonic or rectal surgery, in terms of anastomotic leak rates, surgical site infection, intra-abdominal collection, mortality, reoperation or hospital length of stay. Given its potential adverse effects and patient dissatisfaction rates, it should not be administered routinely to patients undergoing elective colorectal surgery.

Chris Jones, Guildford.


The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway.

Chand M, De’Ath HD, Rasheed S, Mehta C, Bromilow J, Qureshi T. Int J Surg. 2016 Jan;25:59-63.

What is already known:

The wide-ranging benefits, including reduced hospital length of stay (LoS), of both laparoscopic surgery and ERAS have been well established. Perioperative complications are known to increase hospital LoS and mortality.

What this paper adds:

This study included a broad range of surgical procedures performed by a single surgeon using a standardised operative and anaesthetic technique. Details of patient inclusion/exclusion or compliance to ERAS guidelines are not given but it is inferred that all patients, having been recruited consecutively during the trial period, were fully followed-up with no exclusions and that there was no deviation from ERAS guidelines. The study protocol mentions the use of diclofenac, apparently as standard, for all procedures including those involving anastomosis creation (around 80% of procedures) with a 1% anastomotic leak rate. Ten patients were noted to have had a post-operative complication prior to initial discharge of which nine were classed as minor (Clavien-Dindo classification I or II) and these patients were all discharged on day two or three. The statistical analysis, however, showed an adjusted odds ratio of 16.26 for patients suffering a complication being more likely to experience a delayed discharge from hospital. It was also suggested that the study was likely underpowered to look into the effect of complications upon hospital LoS. 27 patients (9%) required readmission, the reasons for which are not detailed. Increased BMI and duration of operation were also suggested as predictors for delayed discharge but these had adjusted odds ratios of 1.06 and 0.99 respectively and of limited clinical significance.

Ben Morrison, Guildford.


Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A prospective cohort study.

Pisarska M, Pędziwiatr M, Małczak P, Major P, Ochenduszko S, Zub-Pokrowiecka A, Kulawik J, Budzyński A. Int J Surg. 2016 Dec;36(Pt A):377-382.

What is already known:

Higher compliance with all the ERAS elements have been shown to improve outcomes, including longer term oncological outcomes. Most single centre studies look at their population as one group, and compares to another control group, but this Polish study aimed to assess short term outcomes based purely on compliance. They split the patients into three groups – high compliance (>90%), medium (70-90%)and low compliance <70%.

What this paper adds:

This study adds further weight to the argument that increased compliance improves short term outcomes. But interestingly not just between low and high compliance but also between medium and high compliance.

Chris Jones, Guildford.


A Meta-Analysis: Postoperative Pain Management in Colorectal Surgical Patients and the Effects on Length of Stay in an Enhanced Recovery After Surgery (ERAS) Setting.

Chemali ME1, Eslick GD. Clin J Pain. 2017 Jan;33(1):87-92.

What is already known:

Well managed pain relief aims to minimise side-effects and enable the main goals of ERAS to be achieved, including early mobilisation and early nutrition.

What this paper adds:

Optimal analgesia is an essential part of a successful ERAS programme, so the authors should be commended for conducting this important review. They included 21 separate RCT’s of several different types of analgesia comparisons, eg Lidocaine vs epidural, epidural vs PCA etc. This meta-analysis included colorectal RCT’s with pain as a major part of the study and length of stay as the main outcome. Overall they found no difference in their main outcome which was length of stay. However there are a number of flaws in this review. The studies they used were a mix of open and laparoscopic surgery, and not clear if all studies used a comprehensive ERAS programme as part of the standard care, in which case its difficult to draw accurate conclusions.

Chris Jones, Guildford.


Introducing an ERAS programme across a provincial healthcare system.

Nelson G, Kiyang LN, Crumley ET, Chuck A, Nguyen T, Faris P, Wasylak T, Basualdo-Hammond C, McKay S, Ljungqvist O, Gramlich LM. Implementation of Enhanced Recovery After Surgery (ERAS) Across a ProvincialHealthcare System: The ERAS Alberta Colorectal Surgery Experience. World J Surg. 2016 May;40(5):1092-103.

What is already known:

Most ERAS studies have been single centre and this is one of the first to describe how ERAS for colorectal surgery was implemented into a wider healthcare system in Alberta, Canada.

What this paper adds:

This study reports detailed results from six of Alberta’s 59 hospitals (but perform >70% of all colorectal surgery). After the ERAS programme was introduced compliance improved from 39% to 60%. They demonstrated an overall decrease in length of stay (6 to 5 days), readmissions, complications and some impressive cost savings (between $2806 and $5898 USD).

Chris Jones, Guildford.